New Patient Registration Form

Date of Birth DD/MM/YYYY

Sex at Birth :

Gender Identity

Home Address

Postal Address

Contact Detail

Medicare Details

DVA White or Gold Details

Pension or Health Care Card Details

Do you identify as

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait Islander

Next of Kin

Emergency Contact

Personal details

Do you smoke:

Do you drink alcohol:

Stratford Medical Centre and Wheels of Wellness participate in Quality Improvement involving the sending of de-identification information for Health Data. Please inform reception if you do not wish to participate.

Privacy

Your medical record is a confidential document. It is always the policy of this practice to maintain the security of personal health information and to ensure that this information is only available to authorised members of staff.

Please refer to our Privacy Policy located at Reception or via our website.

Do you consent to the Doctors at Stratford Medical Centre uploading and accessing your My Health Record?

Yes

Do you wish to receive SMS notifications from Stratford Medical Centre?

Appointment reminders

Yes

Clinical Reminders

Yes

Clinical Communications (Results & Clinical Messages)

Yes

Health Awareness (Leaflets & Database)

Yes

Do you consent to the Staff at Stratford Medical Centre sending Emails to you which may contain private/clinical information?

Yes

If you request to communicate with us via email, we remind you that this is not encrypted, and we do not send information via this means, without your consent.

Digital Signature

Date